HSC Medicine Collection Guide
See also:
- HSC General Collection Guide for information that applies to both HSC Medicine and HSC ICU Data collection.
- Medicine Curriculum for information that applies to Medicine Data Collection at all sites
- ICU Curriculum for information that applies to ICU Data Collection at all sites
HSC wards
Medicine Database for CCMDB is collected on six medical wards at HSC including following any admissions in other areas/wards in the hospital that are under Medicine service attending physician's care.
- A4
- B3
- D4
- D5
- H4
- H4H - HOBS - High Observation Unit (labeled by cubicles)
- RR5 & RR6 now used as overflow for Medicine services A,D & H but may also have direct admits from ER which need to be accounted for.
We collect data on all patients admitted to these wards including teaching,non-teaching and off service. For example neuro medicine patients are included. Another example renal patients under nephrology are included.
H733 no longer in existence
Paper Worksheets used
- optional preference of the data collector to have paper records
- Notes can be left by double clicking on the note section, at the time of sending files delete the notes. You may need to leave notes that are relevant to that file for example a abnormally high wbc.
Daily ward Admit/transfer/discharge ward Binder
- The standard Admission / Transfer / Discharge ward Log Binder that is used and found at the main desk.Some wards write in the details other use a paper label stamped with the addressograph
- The ward also has a scribbler that usually has the names of patients admitted,discharged,transferred and moved.
- The data collector reviews the Admission Binder on each ward, assigns a serial number and enters the minimal data base for all new admissions.
- The admission and discharge "times" are entered as per the Admission binder. Times are corrected once the chart is reviewed.
Information relevant to A4 data collection
- If the Discharge Planning Screening Tool is not found in the chart for a new admission, it will usually be on a clip-board hanging by the door next to the med room (about half-way down the wall). This is done as a reminder for the ward clerk to fax consults on the new admissions first thing in the morning. Once faxed, the tool will be filed back into the chart.--CMarks 10:37, 2013 December 4 (CST)
Information relevant to patients admitted to D4
- D4 is a teaching medical ward which in close proximity to the renal clinic,and specializes in renal patients. It is the designated ward for the renal transplant patients which includes post operative care
Data Collection for Renal Transplant Patients
see Renal Transplant
Renal Donor Patient
- Patient type is surgical
- They are admitted from recovery room.
- Initial vital signs are taken from the last recorded in recovery.
- The admission diagnosis will be 80100 - NEPHRECTOMY 80101 - Kidney Donor
- The Nephrologists state the donors always have a renal biopsy on the donor kidney, but the surgeon may not document this.
- ADL's are to reflect the patient's level of independence prior to surgery (home).
Information relevant to patients admitted to B3
- B3 is both a medicine, and surgical unit.There is no B medicine service. The unit is split into two, ten beds to medicine, the rest to day surgery.
There is a white board opposite the main desk and the inpatients (which are medicine) are written in Black. Cathy is the unit clerk and is more then willing to help any new comer out. Space is very limited on B3 log book is kept at the desk--PStein 12:07, 6 December 2010 (CST)
Technical Support
- If you are having problems with the laptops you need to call the Technical Support.